Clinical Quality Improvement and Risk Management

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Clinical Quality Improvement and Risk Management
Jag Dhaliwal

• Refs, Quotes and Slide adaptation from R
  Silverstro, Universtiy of Warwick
• Ing. Pedro del Campo, Universidad del CEMA

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Learning Outcomes for Today

• Quality
• Perspectives of Quality
• Service Concept
• Sources of Competitive Advantage
• Service Analysis Tools
• Process Flow Analysis
• Service Blueprinting
• Operations Management

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Quality

• How do you know that you are providing quality
  to patients/clients/customers?
• Individually 1 min
• In groups 5 mins
• Group discussion

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Quality

• "Conformance to specifications" (Phil Crosby in
  the 1980s). The difficulty with this is that the
  specifications may not be what the customer
  wants Crosby treats this as a separate problem.
• "Fitness for use" (Joseph M. Juran). Fitness is
  defined by the customer.
• A two-dimensional model of quality (Noriaki Kano
  and others). The quality has two dimensions
  "must-be quality" and "attractive quality". The
  former is near to the "fitness for use" and the
  latter is what the customer would love, but has
  not yet thought about. Supporters characterise
  this model more succinctly as "Products and
  services that meet or exceed customers'
  expectations".
• "Value to some person" (Gerald M. Weinberg)
• (W. Edwards Deming), "Quality is pride of
  workmanship." See http//www.deming.org/
• Quality is the minimum loss imparted by the
  product to society Taguchi 1980

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Which of these Cars Offers Quality?
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Service Concept

• A Service Concept describes the way in which an
  organisation would like to have its services
  perceived by its customers, employees and
  shareholders.
• J. Heskett, Managing in the Service Economy

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Service Concept

• Examples
• Walt Disney to make people happy
• Cristian Dior to give women unlimited
  opportunities
• Microsoft to put a personal computer on the
  study desk of each home

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The Five Performance Objectives
Quality
Being RIGHT
Being FAST
Speed
Dependability
Being ON TIME
Competitiveness
Flexibility
Being ABLE TO CHANGE
Cost
Being PRODUCTIVE
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Which e
n
ables you to do things cheaply (cost advantage)?
Which e
n
ables you to change what you do (flexibility
advantage)?
Which e
n
ables you to do things quickly (speed advantage)?
Enables you t
o do things on time (dependability advantage)?
Being able to do things right (quality advantage)?
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UK Primary Care

• Primary Care Service Concept
• 1960s
• Primary Care role very limited
• Few interventions 15 effective medicines
• Team? What team?!
• More home visits
• More time with the patient (social interaction)

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UK Primary Care

• Contemporary Primary Care Service Concept
• Extended Role of Primary Care a Primary Care
  led NHS
• More than 90 of all clinical activity is
  handled in Primary Care alone
• Team work is fundamental we each have our own
  contributions to make to the health of the
  patient
• Less visits at home
• Less social time with the patient

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A point of view of some of our colleagues and
some of our patients

• I remember the time when the doctors and nurses
  took care of you the doctor would pop in for a
  visit and have a cup of tea .
• Now trying to see your GP is impossible you
  need to see the nurse first.
• My GP always seems to be sending me to see other
  people health visitors, physios, chiropodists
  . in the past, the doctors could deal with all
  of this themselves ..... !

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What it is happening!

• We offer extended services
• The benefits of EBM more interventions of
  quality assured
• eg.  Drugs for the prevention of coronary disease
  
• Treatment of ulcers of the legs by nurses of the
  community,
• We feel we offer quality, but sometimes, patients
  do not feel that they receive quality services
• Why is this so?

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How do our patients judge the quality of
service they receive from us?

• Or How you judge the quality of the service that
  you receive from your car mechanic?

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Perceptions of the Quality of Health Services

• Professional Quality
• 1. Outcome  Whether the service meets the
  professionally assessed needs of patients
• 2. Process  Whether the service correctly
  selects and carries out the techniques and
  procedures which professionals believe meet the
  needs of clients
• Client Quality
• Whether the beneficiary of the service perceives
  the service ace giving them what they want
• J. Øvretveit , Health Service Quality

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The Continuum of Perceived Service Quality
Expectations Not Met
Unacceptable quality
Prepurchase Expectations X
Perceived process X quality
Perceived output quality X

Acceptable quality
Expectations Met
Ideal quality
Expectations Surpassed
Quality Counts in Services Too L. Berry elt al.
Business Horizons
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The Gap Between Expectations and Perceptions
Expectations

Service Quality Gap
0
time
Perceptions
_
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Operations Management

• Objectives
• What is meant by Operations?
• Operations Management
• Modern Paradigms
• Antecedents
• The Perspectives of Operations Management
• The nature of Services
• The Importance of Analysing Processes
• Process Flow Analysis/Service Blueprinting
• Relevance of this theory to our work

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Organisations

• Strategy vision, leadership
• Operations

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Business Functions

• MARKETING
• (Publicity, sales, distribution etc.)
• OPERATIONS
• (Production of goods and services)
• SUPPORT FUNCTIONS
• (Human Resources, Accounting and Finance, audit
  etc.)

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OPERATIONS

• The production of goods or the provision of
  services
• Quality assurance in processes or products
• Making decisions associated with these tasks

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What is Operations Management?

• The study of concepts, methods and tools used to
  identify and to solve the problems related to the
  production of goods and services
• It is a core role for any organisation
• Each company has something to sell or something
  to provide (to satisfy a need). This must be
  produced

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Some Contemporary Paradigms

• Continuous Improvement and Total Quality
  Management
• Lean Manufacturing and Just in Time
• Business Process Re-engineering

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Antecedents

• Craftsman/workshop production little dedicated
  attention to thinking about new methods of
  production if it works, why change it?
• Production Line (Ford)
• Product
• Standardised
• Large volume of goods
• Cost competition make it cheaper
• Process
• In a sequence
• Efficient
• Little flexibility
• Low cost Low quality
• Paradigm until 1970

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The Revolution in the Management of Services

• Japanese enterprise revolution
• The ideas of Juran and Deeming regarding quality
  are widely accepted as having been influential as
  well as Japanese cultural factors.

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The Japanese Perspective of the Management of
Services

• What does not contribute Added Value is wasteful
• Inventories
• Transport
• Control of Waste
• Faulty goods time wasting costs of not
  providing quality
• Flexibility  Fast adjustment to demand
• E.g. motorbikes, cameras
• Quality  To fulfill and surpass the
  expectations of the client Low cost with ever
  increasing quality

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The Service Industry Perspective

• Total Quality Management
• The use of theories and models to analyse
  productive processes
• Eg Process Flow Analysis

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A PRODUCTIVE PROCESS

• Inputs (energy, materials, manual labour, capital
  and information)
• undergo a conversion process (transformation)
• and either new products (goods or services) or
  additional information are generated.
• Information or feedback to make the necessary
  adjustments in the process follow

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Services are different

• Characteristics of Services
• The client is an integral part of the operations
  process of service businesses
• A radio can be made without the client being
  present.
• Not really possible when considering the
  administration of an injection!
• Services are intangible
• They cannot be stored
• They occupy a temporary dimension  They take
  place at the moment at which they are given to
  the client
• Human (as opposed to machine) labour is more
  critical to their success

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despite these differences, services still
consist of processes that can be analysed
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Analysing Processes Process Flow Analysis

• Process Flow Analysis theory (handouts and
  presentation)
• Process Flow Analysis demonstration
• Service Blueprinting - handout

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EXCELLENT PROCESSES

• Imperative to clearly know the mission (Service
  Concept) of the organisation in operational terms
  what is the organisation about?

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The Need to Get it Right

• Investments to improve service may not come back
  as profit gains. Indeed a lot of money is wasted
  in organisations every year in the name of
  quality improvement. From adding costly service
  features that are unimportant to customers to
  spending training money unwisely, it is quite
  common for organisations to throw money away
  pursuing better service quality.
• Zeithaml, Parasuramn and Berry

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• But which processes are critical?
• In our industry the Patient Pathway

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DESCRIPTION AND ANALYSIS OF PROCESSES

• The main processes that add value in achieving
  the service concept of an organisation
• Information systems that describe the approach to
  follow in each situation (Knowledge Management)
• Information systems that register activity

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Operations Management Strategy
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Linking the fundamental perspectives in
Organisations   From the Strategic to the
Operational

• To Direct
• Strategy
• Service Concept
• To Organise
• Service Design
• To Operate
• Processes
• Control quality and value

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Strategy - Service Concept
People To organize
Structure
The People
Organisation
Service Design
Resources Product
/Service To
Operate
Providers
Clients
Organisation Results
Stakeholders
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Propulsors for Change
Outside-In
Bottom-Up
Top-Down
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What is the role of the operations function?
Operations
Operations
Operations
as effector
as follower
as leader
Strategy

Ops

Strategy

Ops

Ops

Strategy

Operations
Operations
Operations
implements strategy
supports strategy
drives strategy
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The strategic role of operations can be defined
by its aspirations (Hayes and Wheelwright)
Redefine the industrys expectations
Give an Operations Advantage
Externally supportive
Be clearly the best in the industry
Link Strategy With Operations
Internally supportive
Increasing contribution of operations
Be as good as competitors
Adopt best Practice
Externally neutral
Stop holding the organisation back
Correct the Worst Problems
Internally neutral
STAGE 1
STAGE 2
STAGE 3
STAGE 4
The ability to Drive strategy
The ability to Implement
The ability to support Strategy
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